The explosion of health care technology has resulted in a massive increase in the amount of information generated about a patient. For instance, in caring for a patient, tens or hundreds of individual data points can be created daily. Information is spread among various locations and systems. No health care worker is able to track down all the data items, assimilate the information, make the translation to knowledge, and create a decision. As a result, the error rate in health care delivery has increased exponentially. Thousands of deaths per year are felt due to errors in the implementation of testing and therapies in hospitals. The technicians, doctors, and nurses are unable to manage the details of diagnosis, treatment, medicine interactions, collection of test results, and communication. In general, the information that is selectively ignored exists in the hospital information systems, but is not easily accessible at the time the care is delivered, or is buried in a mountain of irrelevant information.
Currently pivotal medical-decision-making proceeds at a rate limited by the ability of individuals to proactively acquire all appropriate data at appropriate times. Therefore, it will be appreciated that for information to be useful, it must be presented in a useful manner to a healthcare provider and members of the care team. Real-time information that applies to a current decision maker for a current patient may be relevant, whereas other, outdated or irrelevant information that does not apply to a current decision-maker may be irrelevant. It is not sufficient for the information to exist, but must be obtainable; information must be brought to the hands and eyes of a caregiver at the exact moment it is needed.
As an example, two of the most common preventable causes of hospital death are catheter related blood stream infections and pulmonary embolism. Preventing these complications is largely a matter of removing unnecessary catheters and providing a daily dose of blood thinner, respectively. Unfortunately, healthcare providers and members of the care team miss nearly half the opportunities to take the appropriate action at the right time. A significant problem is that healthcare workers are bombarded by dozens of similar opportunities for every patient and work as individuals in parallel, rather than in concert, with one another. Catheters and blood clots are only a fraction of the things vying for attention. Good intentions of healthcare workers are devoured by volume, complexity, competing demands, and the lack of a shared vision for what must get done immediately.
On the rare occasions when providers and nurses become aware of missed opportunities, the performance data that is seen is retrospective and invariably derived from sampling a small portion of the patient population. This traditional model of performance tracking has marginal value and in today's digital environment should be retired.